Key Policy Issues in Incorporating Health Equity into Health Care Reform

Key Policy Issues in Incorporating Health Equity into Health Care Reform Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute & Associate Professor, University of Texas School of Public Health Federal State Discourse on Building an Equitable Health Care Delivery System National Academy for State Health Policy Washington, D.C. January 8, 2015

ACA s Vision to Advance Health Equity Monitoring health care reform from a health equity lens since 2007 Our 2010 Report found that working to advance health equity is central to the ACA.

Definition of Health Equity Health equity is assurance of the conditions for optimal health for all people. Achieving health equity requires valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources according to need. Health disparities will be eliminated when health equity is achieved. - Camara Jones, CDC, 2011

Over 60 provisions in the ACA that explicitly or through more broader initiatives intend to advance health equity

Overall Progress of ACA s Health Equity Objectives Implementation Progress of ACA's Equity Provisions October 2013 (N = 56 Provisions) Not Funded or Implemented 23% Partially Funded or Implemented 29% More Fully Funded or Implemented 48% Health equity advancing provisions that have seen the greatest progress are generally those related to health insurance reforms.

Health Insurance Marketplaces Marketplaces will cover nearly 30 million 42% (12 million) projected to be non-white 25% projected to have limited English proficiency (LEP) Overall Open Enrollment 1: 6.7 million successfully enrolled in marketplace Approximately 28% of potential population enrolled Enrollment by race, ethnicity, and language (REaL): Enrollment experience varied REaL Estimates are very rough as reporting REaL data was optional Generally, Hispanics/Latinos, African Americans, LEP populations lagged in enrollment Low hanging fruit phenomenon

Medicaid & Coverage Gap 80% 70% 60% 50% 53% 74% Percent of Non-White Population in the Coverage Gap, 2014 67% 64% 61% 58% 54% 53% 47% 45% 45% 43% Medicaid has covered at least 5 million new individuals. However, states not expanding are disproportionately disenfranchising non-whites. 40% 30% 42% 40% 36% 36% 35% 33% 29% 29% 25% 20% 10% 0% Source: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels and 2012-2013 Current Population Survey.

Safety-Net Systems at a Crossroads: How to be providers of choice while continuing to serve their mission?

Monitoring Safety-Net Systems Transformations at Public Hospitals in Medicaid Expansion States Supported by Blue Shield of California Foundation Goal: Identify delivery system transformation models, experiences, challenges, and lessons learned in adapting and responding to health care reform Study hospitals: AEH public hospitals and select other safety-net systems in Medicaid expansion states with at least 50% Medicaid and self pay mix. Also reviewing transformations through Medicaid 1115 Waiver Programs (e.g. DSRIP)

Study Safety-Net Hospitals Hospital Name State Provider Type AEH Member Public Hospitals Boston Medical Center MA Public Hospital Cambridge Health Alliance MA Public Hospital Cook County Health & Hospitals Corp IL Public Hospital Hennepin County Medical Center MN Public Hospital Maricopa Integrated Health System AZ Public Hospital MetroHealth System OH Public Hospital Mount Sinai Hospital of Chicago IL Public Hospital Table 1. Study Safety-Net Providers NYCHHC - Elmhurst Hospital NY Public Hospital UK HealthCare Hospital System KY Public Hospital UW Harborview Medical Center WA Public Hospital Other Safety-Net Providers Clinica Family Health Services CO FQHC Maui Memorial Hospital HI Public Hospital Yuma District Hospital CO Critical Access

Safety-net provider interviewed

KEY FINDINGS 1. Turning the dial away from fee-for-service, and transitioning toward capitated approaches that reward population health outcomes. Nearly all providers have already or will soon move away from fee-for-service payment and delivery in favor of capitation. More than half of interviewed hospitals are currently part of Accountable Care Organizations (ACOs). Shift toward capitation occurring gradually i.e., systems in a two canoe situation

KEY FINDINGS 2. Redesigning primary care to be better coordinated, patient-centered, multidisciplinary, & team-based. Shift to Patient Centered Medical Homes (PCMHs) Team-based care approaches Encouraging top of the license practice Adding non-medical staff to teams e.g., lay health workers Increasing billable time e.g., Clinica s FLIP visits Addressing social determinants in primary care setting Health Corridor connecting health, housing, and transit across five neighborhoods (e.g., MetroHealth) Team-Based Coordinated Care Center for complex patients with frequent hospitalizations, chronic conditions, and socioeconomic challenges (e.g., Hennepin)

KEY FINDINGS 3. Undertaking strategies to be more competitive, especially to retain patients. Safety-net executives say long-term viability depends on retaining patients in competitive environment Strategies to respond to competition include: Culturally and linguistically appropriate services Investing in outreach & enrollment efforts Re-branding campaigns to be perceived as providers of choice, not providers of last resort Undertaking collaborative vs competitive efforts

KEY FINDINGS 4. Embracing change through leadership. Leadership transitions have occurred in at least 4 hospitals, accompanied by changes to improve the financial position of the system, including: 1. Assuming short-term risk for long-term savings Investment in medical homes or accountable care arrangements 2. Consolidation Co-locating and downsizing facilities (e.g., BMC) 3. Management restructuring Hierarchical to flat structure facilitates efficient decision-making (e.g., Cook County)

KEY FINDINGS 5. Undertaking cost-cutting strategies Reducing waste and unnecessary costs Streamlining administrative processes Adopting transparency in pricing for common inpatient & outpatient services Hospital can reduce uncompensated care when uninsured patients can realistically evaluate their ability to pay (e.g., Maricopa)

Opportunities through 1115 Medicaid Waivers States that experienced success in their payment and delivery system reforms shared 5 key elements -- 1. Focus on patient-centered medical homes 2. Primary care & behavioral health integration 3. Collecting and sharing data 4. Moving ambulatory care out of ED and into community-based settings 5. Transition to capitated approaches, away from fee-for-service Reform reinventing the wheel! Basics already exist: Medical homes Health IT Community health teams Stakeholder engagement

What Keeps Hospital Executives Up at Night? Uncertain role and relevance of safety-net institutions : where do we fit in the puzzle and what is going to define us Challenges associated with shifting delivery and payment structures: especially for already struggling institutions that may not have capital or resources to take on added risk Financial viability/vulnerability: looming federal DSH reductions, new penalties, state/local budget cuts, primary provider for low-income and uninsured Challenges with transitioning staff especially with resistance to change from some systems that are highly unionized, as well as from physicians and other providers.

Moving Ahead: Points for Consideration Assuring patients and communities are at the heart of new delivery and payment reforms Whole person care Addressing social determinants Accountable Care Communities Managing transformation will require a unified vision, leadership, and innovative collaborations Championing leadership Revisiting vision and objectives to assure relevance in evolving health care environment New partnerships e.g., UW Medicine & Boeing

Moving Ahead: Points for Consideration Transitioning and supporting health care workforce Education and training on evolving delivery and payment system, with evolving roles Importance of whole person and social determinants Monitoring transformations to assure they do not exacerbate disparities At the community level Among providers Between patient populations

Health Equity & Marketplace Report Card Funded by W.K. Kellogg Foundation, The California Endowment, and Connecticut Health Foundation Goal: Develop and administer a report card to assess marketplace progress and performance in advancing racial and ethnic health equity. Objectives: 1. Identify how, and to what extent, health equity is integrated into marketplace plans and operations. 2. Document progress and outcomes of efforts to advance health equity, identifying program successes and gaps. 3. Identify opportunities to enhance efforts to advance health equity through health insurance marketplace.

Health Equity & Marketplace Report Card Dimensions Marketplace Structure & Governance Equity Related Financing & Resources Collaboration & Community Engagement Marketing & Communication Consumer Assistance Programs Measurement & Evaluation Consumer Enrollment and Satisfaction Access to Care

Contact Information Dennis P. Andrulis, PhD, MPH Senior Research Scientist Texas Health Institute & Associate Professor University of Texas School of Public Health dpandrulis@gmail.com http://www.texashealthinstitute.org/ health-care-reform.html